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Abstract

What will the healthcare system and healthcare organizations look like in the year 2020? What requirements will they have for health human resources? These two questions require both a careful consideration of the general direction of change in health systems and a consideration of the pace of change over the next 15 years. The geographical focus of this article is Ontario, although broader international and Canadian trends are also considered in arriving at answers.

This article is organized in five brief sections, beginning with looking backward to look forward and proceeding through key trends, organizational evolution by sector and future health organizations and concluding with 10 implications for health human resources.

Looking Backward to Look Forward

Do organizational changes impact on health human resource
requirements? The answer, looking at the history of the past 15
years in Ontario, is a resounding "yes." It is worth considering
major health and human resource policy decisions taken in the past
15 years with a view to gaining insight into those decisions in the
go-forward 15-year period. It is also worth considering the
organizational changes that the healthcare system has undertaken to
see trends. Put briefly, in the 1990s, we witnessed decisions on
both physician human resources and nursing education that were
taken in different manners, but both ended up moving the health
system in the wrong direction. We reduced our training and
education capacity at exactly the wrong time in nursing and
medicine. Worse still, it took nearly a decade for corrective
actions to be taken. A central reason for the policy errors was a
lack of explicit linkage between organizational change and health
human resource decisions. In the case of medical education,
explicit decisions were based on intended organizational changes
that were not implemented. In nursing education, organizational
changes that were implemented led to unintended reductions in
nursing education numbers.

The physician decision was taken at the national level based
upon the Barer-Stoddart study (Barer and Stoddart 1992). The study
and its implementation missed two important realities. First, the
physician population was shifting from male dominated to more
balance between male and female physicians. This held the
implication that the average future physician would deliver less
care than the average current physician. Second, recommendations
were cherry-picked, that is, only some were implemented. Therefore,
physician numbers were based on a prediction that did not unfold.
In particular, the reform of primary care, a subject to which we
will return shortly because it has great relevance to the next
15-year period, was not undertaken in parallel with the training
reductions. In fact, it may be that one of the most powerful
decisions in terms of health human resource planning in the next 15
years turns significantly on the success of the movement to
interdisciplinary teams in primary care, for reasons that will be
outlined subsequently.

The nursing decision was not taken on the basis of any overall
study; it resulted from dozens, if not hundreds, of individual
decisions at university, community college and hospital levels, all
of which led to a dramatic reduction in the number of nurses
educated. Organizational consolidation unrelated to nursing
education had the impact of dramatically reducing the number of
nurse graduates.

Both the decisions regarding physicians and nurses have been
reversed. Significant increases in the number of nurses and
physicians being trained are under way. It is not clear whether the
increases are sufficient to offset just current shortages or
whether they will also be sufficient to address an increase in
retirements. Over the next 15 years, the retirements of baby
boomers, who constitute a significant percentage of professionals
in the health labour force, will represent a major shift.

Looking backward should tell us that there is an important
connection between how we choose to organize health services and
what human resource requirements result. For example, reordered
primary care with multidisciplinary teams will require fewer
doctors than solo practice family medicine. However, a shift of
nursing work from hospital settings to home settings will not
require fewer nurses.

Key Trends

It is my objective in this section to separate key trends that have
an inherent impact on organizational structure in healthcare
delivery from those that do not. The broad categories of trends
include demographical change - largely the aging of the population
- movement to a more consumer-driven health system and
technological change. Having devoted an entire book, Four Strong
Winds, to the forces of change several years ago, it is my
intention to focus on those trends most likely to impact on
organizational structure (Decter 2000).

The past 15 years have witnessed significant growth in the
provision of non-traditional care. By non-traditional, two
different dimensions are indicated. A range of providers beyond the
traditional professional categories is providing more healthcare,
for example, in fields of massage therapy and acupuncture
aromatherapy. There has also been significant growth in the
rehabilitation field; physiotherapy and chiropractic have expanded
as the population has aged and there has been an increased need for
these fields. These services are not provided within the hospital
and physician sectors of healthcare. They will demand a greater
number of skilled professionals. However, this trend is not likely
to impact structure.

By contrast, management of chronic diseases is another sphere
with both unmet needs and future growth. Ontario will experience
the same phenomena as other jurisdictions of an aging population
coping with an array of chronic conditions. Increasingly, experts
are noting that better outcomes are obtained by managing chronic
diseases such as diabetes in a tighter fashion. By 2020, it is
probable that more than one million Ontario residents suffering
from chronic diseases will be enrolled in formal disease management
programs. The successful implementation of such programs will
require structural change, particularly to primary care. Disease
management cannot be carried out readily in a solo family physician
setting. Multidisciplinary teams and robust information technology
including electronic patient records are necessary elements.

Patient demands for timelier, more appropriate and
higher-quality care are also likely to force structural changes in
healthcare delivery. Overall, a movement toward greater integration
of care is likely to meet these consumer-type demands. As well,
greater investments in health information are inevitable to meet
the needs for greater information on the part of patients about
their care journey.

Organizational Evolution by Sector

Although stated goals for healthcare delivery reform espouse a more
integrated system, Ontario's current realities are still a health
organizations differentiated by the care they are delivering.
Unlike provinces such as Alberta or Saskatchewan where a regional
health authority delivers hospital care, home care, public health,
chronic care and other types of care, in Ontario the organization
form varies by sector. The mandate of the 14 Local Health
Integration Networks (LHINs) is to plan, coordinate and fund health
services, not to directly deliver care services.

Hospitals

For more than a decade, the major trend affecting hospitals
worldwide has been a continual shortening of length of stay. Due to
technological change as well as financial pressure, hospitals have
moved 70-80% of their surgeries to a day basis. For the remaining
surgeries, there has been an ongoing effort to shorten the lengths
of stay. In many cases, this shortening has been dramatic. For
example, in obstetrics, an average length of stay of five to seven
days was not unheard of two decades ago. Now 24- and 48-hour
lengths of stay are more typical. Whole classes of surgery have
been moved from an in-patient to an outpatient basis. In addition,
the entire enterprise of surgery of an exploratory nature has given
way to much improved diagnostic imaging.

In 2005, for the first time in a decade, average length of stay,
including that in Ontario hospitals, increased slightly. Whether
this marks the reaching of a plateau, to be followed by an increase
in length of stay, or whether it simply marks a deceleration in the
shortening of length of stay will require several more years of
data. What is significant is that the most dominant trend driving
staff requirements for hospitals seems to have come to a resting
point. The stabilization of lengths of stay coupled with the
demographics of an aging population will result in more
hospital-based surgeries, particularly for procedures such as joint
replacements. (The trend is less clear in the case of cardiac
surgery, where the innovation of coated stents seems to be driving
a reduction in cardiac bypass surgery.) Overall, the trends seem to
suggest that the decline in the hospital sector from roughly 50% of
total health spending and total healthcare activity to about one
third is stabilizing and is likely to remain in this range or even
to begin to increase slightly. The implication for health human
resources is that hospital staffing will require replacement on the
demographic basis of all those workers retiring over the next 15
years.

Primary Care

If primary care in Ontario continues to move from a largely
fee-for-service family physician model toward the larger practice
groups with multidisciplinary teams, this will have a profound
impact on health human resource planning. At the present time, the
Ontario physician population of some 22,000 is equally divided
between family physicians (48.5%) and specialists (51.5%). Over the
next 15 years, not only will Ontario's population grow by perhaps
20-30%, the population will significantly age. The percentage of
the population over the age of 80 years will expand dramatically,
and that of the population over age 65 a little less dramatically.
Both of these trends will increase the need for primary care. In
particular, the need will be greater for assistance to patients and
their families for the management of chronic diseases such as
diabetes, heart disease, asthma, arthritis and cancer. The burden
will not be easily borne by a system organized around the solo
practice family doctor.

In 2004, Ontario had 10,656 family physicians. Of this group,
6,859 (64%) were men and 3,797 (36%) women. If one looks at those
physicians over the age of 55 years - that is, those likely to
retire by 2020 - a different picture emerges. In this group, there
are 3,124 physicians, 2,541 (81%) of whom are men. By 2020, the
family physician workforce in Ontario will experience the
retirement of 29% of its ranks. The new physician population will
be close to gender balanced. The dominant form of primary care
organization will have ceased to be the solo practice family
physician. Reordered multidisciplinary primary care teams will have
become the dominant form of organization.

Major efforts are already under way by the second successive
government to create more integrated primary care. The main
obstacles are threefold: (1) provider resistance, largely from the
longer established members of the professions, (2) the electronic
patient records needed for technology integrated care and (3) the
absence of sufficient numbers of non-physician health professionals
to make up the multidisciplinary teams. Simply put, team practice
will substitute nurse practitioners, nurses, dietitians,
physiotherapists and others for family physicians. If there are
insufficient numbers of these other health providers, the reform
will fail.

By way of example, one were to contemplate in Ontario a ratio of
one nurse practitioner to every three family doctors, one would
require 3,000-4,000 nurse practitioners. Yet only 800 nurse
practitioners exist in the whole of Canada at the present time.
Ontario's current policy directions favour increasing the number of
physicians and nurses but show little trend toward increasing the
number of nurse practitioners. If, instead, that ratio were one
nurse practitioner for every two family doctors, Ontario would need
6,000 nurse practitioners. It is likely that some nurses already
employed in primary care will upgrade their skills; nonetheless, a
clear implication for health human resource planning in Ontario is
not only the direction of primary care reform but its pace. At
times, ambitious targets have been set by governments (80% within
three years, by the Honourable Tony Clement) and not met (Ontario
Ministry of Health and Long-Term Care 2002).

Home Care

Home care continues to expand as an aging population requires more
care in the home, both to prevent hospitalizations and to allow
recovery post-hospital procedures. The impacts of the
purchaser-provider split and a tendering system implemented through
the community care access centres (CCACs) have been to consolidate
the home care sector into larger province-wide delivery
organizations.

Health Informatics

Another major challenge facing the Ontario healthcare delivery
system with implications for health human resources is the
implementation of the electronic health record. Although Smart
Systems for Health exists and employs a considerable group of
direct employees and consultants, the bulk of the activity in
health informatics is taking place at the level of individual
health organizations. Hospitals and other healthcare organizations
are revamping their spending on informatics from 1-2% to 5-6% of
their budgets. This trend can be expected to continue with
significant implications to the number of people employed in health
informatics throughout the provincial health delivery system.

It is unlikely that there will be an emergence of a major single
dominant employer in the health informatics area, although it is
possible that the winds could bring some entity into being with a
specific focus. If there were a strategic investor modelled on
Canada Health Infoway, the employment implications might be
similar, with 100 total staff. The number of health informatics
employers throughout the health system is likely to rise steadily
through the next 15 years.

The pace of investment in health informatics will drive the pace
at which the electronic health record is implemented in Ontario.
Even on a slow track without a Malcolm Gladwell tipping point to
accelerate it, it seems clear that all Ontarians will have an
electronic health record by 2020. Their maintenance will employ
thousands, if not tens of thousands, of personnel within the health
system. This will be the second major group of new employees within
healthcare.

Future Health Organizations

Further consolidation of the hospital system is likely in the next
15 years. Over the past 15 years, Ontario reduced the number of
hospital organizations by 25%, from 240 to 180. Whether further
merger and consolidation will follow the regionalization model of
other provinces is not clear. The LHIN reforms could lead to a
further consolidation of delivery; but in the first several years
as the LHINs commence, they are more likely to stick to a purchaser
role and use competition among providers to improve efficiencies
and outcomes. At some point, this process will lead to hospital
organizations that are not as strong, further weakened by their
inability to compete to be merged. A future government may consider
a less gradual consolidation, but that is speculative. In an
evolutionary scenario, Ontario might retain as many as 150 hospital
organizations by 2020. In a more radical consolidation into
integrated health systems, the number of organizations might be
reduced to perhaps 60. The notion that the 14 LHINs will become
monopoly provider organizations with the elimination of individual
hospital and other care provider boards strikes me as unlikely
given the political power of the Ontario Hospital Association and
individual hospital boards.

The implementation of the CCAC purchasing model for home care
has led to a consolidation of home care delivery into fewer, larger
organizations. Although, with the anticipated integration of the
CCAC function into the LHINs and the implementation of some of the
Caplan Report recommendations, it is uncertain whether this will
continue. In fact, the proposal of Elinor Caplan to allow CCACs to
extend contracts will likely diminish the competitive aspect and
secure market share for existing providers in the short to medium
term. Nor are new national agreements on minimum home care
standards likely to affect Ontario as the province has already
financed care in excess of the minimum package required by the 2004
accord among the governments.

Pharmaceutical Care

Pharmaceutical care is worth consideration. As the population ages
and life expectancy continues to slowly rise, the continuing growth
of pharmaceutical care will impact human resources requirements.
The most obvious trend is expanded pharmacies and the displacement
of community pharmacies with chain drug stores. Organizations such
as Shoppers Drug Mart will continue to expand their market share.
They are also likely to continue to increase their offerings of
products for self-testing and patient management of their own
health. A range of new diagnostic tests will be made available on a
direct-to-consumer basis. The pharmacist's role will include
assisting patients not only in managing prescription medications
but in choosing non-prescription medications for common ailments.
The supply of pharmacists and pharmacy assistants will expand
steadily to meet these requirements. It is also possible that, in
smaller centres, other health professionals such as physicians will
locate in the chain drugstores.

Research

The past decade has witnessed impressive growth in the overall
health research enterprise in Ontario. Not only have the
hospital-based research foundations expanded, the government of
Canada has significantly boosted funding for health research
through the reformation of the Medical Research Council into the
Canadian Institutes of Health Research.

Conclusions: Implications for Health Human Resources

Organizational change has important implications for health human
resources. But more powerful may be the grinding of demography on
both the health workforce and the patient population. Let us
consider the top 10 list (with apologies to David Letterman) of
areas in which organizational form and pace of investment will have
the most impact on health human resource requirements:

The emergence of larger-scale primary care organizations
staffed with a mix of physicians, nurse practitioners, midwives,
pharmacists, nutritionists and dietitians will be the major driver
of change. The pace at which this happens will be critical. The key
impact will be a sustained demand for non-physician health
professionals for these new organizations.

In the gradual consolidation scenario, the restructuring of
healthcare delivery services will likely involve the replacement of
a significant portion of the hospital workforce through this
period. Nurses will be the largest group with possible supply
problems. Replacement of nurse retirees will dominate the agenda.
In nursing education, a shortage of educators to cope with the
needed expansion of education will be a challenge.

In the scenario of radical consolidation into some 60
integrated health delivery systems, the human resource requirements
will likely be met by more direct action. In jurisdictions with
larger systems, much more direct linkage to educational
institutions is evident; the integrated systems will enter into
direct relationships to ensure access to new graduates in
sufficient numbers. They will also initiate more robust internal
training and upgrading programs.

Home care sector growth will need to be accommodated by
specific training efforts so that home care is not the poor cousin
to hospital nursing with high turnover.

The pace of health informatics will cause a significant demand
for informatics personnel in health delivery organizations
including hospitals, home care, LHINs and others. By 2020, every
resident of Ontario will have an electronic health record that will
require continual updating.

The continuing growth in the scale and sophistication of
pharmaceutical care will require increased numbers of pharmacists
and pharmacist's assistants. Changes to scope of practice and
reimbursement that might permit prescribing of some medications by
nurse practitioners and pharmacists could also expand human
resource needs in this sector.

Larger, more integrated health services delivery organizations
tend to develop more sophisticated and effective health human
resource development programs. In the documented cases of Capital
Health in Edmonton, a more rigorous planning and forecasting model
has been adopted to predict future needs. In the Montreal Region,
these efforts have included very organized mid-career, middle
management training.

The LHINs are likely to require staff with specialized skills
not readily available in the current healthcare system. It will be
worth considering the 14 LHINs as a separate human resource need to
be met with a combination of measures including mid-career training
in purchasing.

The research enterprise in health will continue to expand with
a need for professionals with PhDs as well as lesser-skilled
technical personnel. Health research will grow most rapidly in the
molecular and gene therapy fields as well as in health
services.

Organizational changes have consequences for health human
resource requirements - sometimes unintended and unpredicted
consequences. This fact leads to a broad point pertaining to the
entire health workforce. It is a reasonable goal to educate a
sufficient number of providers to achieve a modest surplus. Only
with a modest surplus can organizational changes be accommodated
without imposing excessive overtime and resultant injuries on the
existing workforce. A modest surplus is also a way to avoid
poor-quality care.

With regard to timing, the two most significant drivers of
health organization change in Ontario will be the pace and scope of
LHIN implementation and the speed of primary care reform.

About the Author

Michael B. Decter is a leading Canadian expert on health systems, with a wealth of international experience. In 2003, he was appointed as founding Chair of the Health Council of Canada. Most recently, he was the Chair of the Canadian Institute for Health Information. He continues to serve as Chair of St. Elizabeth Healthcare, and the Ontario Cancer Quality Council. He is a Board Member of The National Ballet of Canada and George Brown College as well as part of the Advisory Council at the School of Policy Studies, Queens University.

Acknowledgment

This paper was commissioned by the Change Foundation Health Human Resource Think Tank held in January 2006.

Comments

ping ocampo wrote:

Posted 2012/10/09 at 11:47 PM EDT

Greetings.
In an occupational setting like a geothermal industry. Do you think merging the Human resources department and the medical department would be the best option for the industry and the employees? or would it be better if the medical department although working with close collaboration with HRD must be independendent and not under the organizational structure of HRD?
More power to you!